Kevin A. Lawrence

***** ****** ***.

Parker, CO *0134

303-***-**** HM

805-***-**** Cell

advczi@r.postjobfree.com

Health Claims Insurance expert

Healthcare claims professional with extensive expertise in Self-funded medical plans, Indemnity plans, Medicaid, Medicare and Preferred Provider plans (PPO). Behavioral Health benefits coder. Supervisory experience in Long and Short Term disability plans with knowledge of Workers Compensation coordination. Supervised teams for Self-funded disability plans for private companies and State mandated plans for disability insurance in California. Development and management of process improvements and developing strategies, programs and practices to streamline production and follow through to meet and exceed turnaround times for processing. Core competencies include:

Claims Auditing and Appeals adjustments

Processing Medical & Dental Claims

Disability Long and Short Term

Medical Claims Processing

Auditing and Adjusting claims

Supervisory Experience

Supervised the medical and dental claims unit for Medicare, Medicaid and CHP HMO plans for employers with Medicare age employees and state plans. Group plans with manage care, indemnity and PPO products. Handled hiring and performance reviews for claims and membership examiners. Tracking claims turnaround times to meet processing incentives for companies. Met with employer groups to evaluate data on services used and benefits administered. Gave options on how to best structure their benefits versus services used in prior periods. Advise of Family Medical Leave Act products, time management and reporting for employees payroll services.

Long and short term disability claim supervisor for private self-funded plans and state mandated plans. Supervised staff on understanding disabilities on treatments. Taught coding and diagnosis turnaround times for various disabilities using the workers compensation official disability guidelines manual. Monitored time tracking and duration management reports to measure against metrics. Held conferences with group administrators on products offered, discussed usage of benefits and where majority of funds were being utilized by their staff. Attended court hearings on benefit denials and appeals of benefits for clients. Defended company guidelines and gathered medical information in support of Independent Medical Examinations either to deny or approve medical disabilities. Paid claims to claimants based on wages and plans selected.

Claims Processing Experience

Processed medical and dental claims for Medicaid, Medicare, HMO, PPO Indemnity plans throughout the United States. Some plans were self-funded by employers for large and small groups, fully insured groups, Medicaid, Medicare and HMO. Processing claims since 1991 for various companies and customer service. Multiple processing systems, QNXT, HRP, FACETS, Powerstepp and Power queue claim systems.

Experience Colorado Access February 2011 to October 27, 2022

Claims, Grievance, Appeals and Auditing Manager

Managed staff of 13 individuals. Two Auditors, Nine Claims Appeals Specialist and two clerks. Claims processors were offshore in India. We process claims and adjustments in the QNXT claims system through Cognizant for CHP HMO claims, State Manage Care Network claims for Maternity plans, previously had accounts for Medicare and Medicaid. We also handle appeals and claims for Accountable Care behavioral health claims for low income families for state plans. I lead our claims team for CMS state regulation audits. Also attend meetings with provider groups on hospital and professional claim processing. We did these meeting once every three months to go over any claim or contract issues. Annual reviews and training for new employees coming to our team. I have written desk top procedures for claims appeals auditing, our adjustment team.

Experience CIGNA/Great West Healthcare June 2007 to October 2010

Senior Appeals Coordinator

Reviewed provider and member appeals for ASO, and fully insured products. Reviewed for under and over payments and plan specific guidelines. Responded within 30 day turnaround time per guidelines. Coordinated responses between medical management and providers for medical necessity of services provided through written and verbal communication. Reviewed claims up to $100K for resolution and response. Handled 2nd and 3rd level appeals within guidelines. Understanding of ERISA guidelines, state guidelines and private employer plans not governed under ERISA. Processed claims on FACETS claim system through Cognizant.

Experience CNIC Health Solutions December 2006 to June 2007

Temporary Claims Supervisor Denver Office

Supervising CSR/Claims team for over 200 clients from PPO products to executive benefits, flexible spending, and Health Reimbursement plans. Monitoring 14 day turn around time and 20 second call service requirement. Reviewing over 10K claims and all medical management referrals. Handled weekly production reports and review of audits for claims representatives. Fielded Account Manager inquires on complex claims situations. Temporary position.

Experience VPA, Inc/Sedgwick, Calabasas, CA June 2000 to March 2006

Operation Supervisor

Manage and processed Short term and Long Term disability claims while coordinating benefits with Workers Compensation and third party liability benefits. Manage funds from employers account via payments, reductions over and underpayments through audits and training of examiners claims. Met with the clients to help mange und understand ways they could alter and better utilize their benefits. Advising of areas of concern through either over or under utilized usage.

Conducted monthly, quarterly and yearly reviews for yearly performance and pay increases for my staff. Handled appeals and grievance issues through written correspondence, court hearings and billing disputes. Handled irate customers and issues where legal representation was present for complex matters. Billing issues and claim submissions for members claims while on leave that were paid through our company. Moved to Colorado 2006.

Experience Prudential/Aetna insurance June 1998 to May 2000

Claims Operation Supervisor

Supervised staff of 25 for medical and dental claims for the western region

Managed meetings between Client Services, Account Mangers and Claims Operation teams to assist with different departments understanding one another allowing the teams to streamline processes. Implemented training course for new employees, also designed training to bring them up to speed to contribute to their departments faster speeding profitability. Handled all appeals issues and customer complaints where it looked like resolution could be reached with the examiner. Billing issues, payment disputes and coordinating benefits payments with various insurance companies.

Experience Health Net, CA March 1994 to June 1998

Claims Supervisor/Claims Examiner/Auditor/Adjuster

Manage team of 30 employees. Handled all interviews, reviews, promotions, demotions, increases, and disciplinary functions of the department. Handled disputes between doctors and billing on HMO and PPO products. Customer issues and personnel issues.

Retrained department in accordance with the Medicare guidelines bringing department into compliance, allowing company to be off of restrictions with the government auditors. Company received and extensions of contract in 1996 through 1999. Processed and audited claims prior to becoming Supervisor.

Company merged with United Insurance and moved operations to Sacramento, CA in 1998.

Experience United Healthcare May 1991 to July 1993

Senior Claims Examiner

Processed medical claims for several accounts, HCFA 1500’s, UB’s and prescription claims. Processed claims using ICD-9, CPT codes, Medical terminology and Hospital Per Diem guidelines for procedures. Met and exceeded 99.5% accuracy rate with Excellent Customer service. Closed claims processing department in March 1993. Handles runout until July 1993.

Experience Blue Cross of California December 1985 to April 1991

Clerical Supervisor

Supervised unit of 30 employees. Handled hiring and performance reviews for all employees. Unit handled all incoming mail, underwriting applications, lock box payments and claims being submitted to Small Group department. Trained department on microfiche retrieval equipment, creating logs, processing systems and designed all work flows to coordinate with claims and membership departments.

Education

Lennox High School, Lennox CA 1981

Basics

Los Angeles Southwest College 1981 to 1982

Business Management

Marketing

Interest

Restoring vintage Volkswagens and old cars

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